Vicki, a 57-year-old woman, has suffered from

Vicki, a 57-year-old woman, has suffered from osteoarthritis for the last 2 years. Since Vicki has a history of aspirin sensitivity (which manifests as bronchospasm), NSAIDs are contraindicated. She initially used paracetamol for analgesia, but due to worsening pain Vicki’s general practitioner prescribed panadeine forte, two tablets 8-hourly. Vicki obtains no additional benefit from the panadeine forte, and in frustration she takes a ‘couple of handfuls’ (later estimated as about 30 tablets) of panadeine forte tablets. After 2 hours Vicki felt nauseous and told her husband what she had done. Vicki’s husband took her to the emergency department of their local hospital. Vicki was immediately administered activated charcoal, 50 g. The plasma paracetamol concentration 4 hours after the overdose was measured as 180 mg/L. What is the likelihood of hepatotoxicity, as assessed from Vicki’s plasma paracetamol concentration? What is the mechanism of paracetamol hepatoxicity?

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